Dental for Everyone Platinum PPO Plan Information

A. Enrollment and Eligibility
Individuals who are 18 years of age, and their eligible dependents (unmarried children from birth to age 26). Individuals 65 years of age and over are eligible to enroll, and will be charged the same rate as those enrollee’s under 65.

B. Your Effective Date
Plan effective dates are always the 1st of the month. If the enrollment form and payment information are received by the 19th of the month, coverage will become effective on the 1st of the following month. Incomplete enrollment forms or failure to submit the required initial premium amount may cause an initial delay in issuance of insurance. Do not cancel any other insurance or assume you are insured under the Plan until you receive your certificate of insurance.

C. How does the Plan work?
As long as you meet the plan's general eligibility requirements and pay the applicable premium, your acceptance is automatic. This plan contains waiting periods that must be satisfied before coverage is available for services.

D. Annual Deductible & Calendar Year Maximums
The annual deductible is the amount of covered dental charges incurred by an insured person or on behalf of your insured dependent before Delta Dental starts paying benefits. The annual deductible of $50 will apply to each insured person for Type 1, 2, and 3, while Type 4 (Orthodontia Procedures) requires a $100 lifetime deductible. The Calendar Year Maximum is the maximum amount payable for all eligible dental expenses in any calendar year. The Calendar Year Maximum for this policy is $1,500 for each insured person.

E. Choice of Provider
Delta offers Delta Dental Premier Plan (Indemnity Plan) or a Delta Dental PPO plan. The Premier Plan rates are based on Delta Dental’s Premier network. Both Premier and Non-Delta Dental dentists are reimbursed on Usual, Reasonable and Customary (UCR) charges. The Premier dentist will file the claim with Delta Dental and will not balance bill. PPO coverage rates are based on Delta Dental’s PPO network. Benefits for all dentists are based on Delta Dental’s reduced PPO fee schedule. PPO dentists will file the claim with Delta Dental. There is no balance billing for PPO dentists.

F. Specialty Care/ Specialty Referrals
Specialty Care can be utilized and the benefits will be applied based on the type of service needed, provided the waiting periods have been satisfied.

G. Emergency Dental Services
Emergency services can be utilized and the benefits will be applied based on the type of service needed, provided the waiting periods have been satisfied.

H. Coordination of Benefits
This plan will be coordinated with any other group, blanket or franchise plan under which an individual will receive benefits. This helps keep the cost of the plan reasonable.

I. Cancellation Policy
The policy may be canceled with 30 days written notice.

J. Termination of Policy
Coverage terminates on the earliest of the following dates:

The last day of the month in which you cease to be eligible for coverage.

The last day of the month in which your dependent is no longer a dependent, as defined.

Subject to the grace period, the last day of the month for which a premium has been paid by you or on your behalf.

The date the policy ends.

K. Exclusions/ Limitations

LIMITATIONSLIMITATIONS ON DIAGNOSTIC AND PREVENTIVE BENEFITS:

Routine oral examinations and cleanings (including periodontal cleanings) are provided no more than twice in a Calendar Year while the person is an Enrollee under any Delta Dental program or dental care program provided by the Contract holder. Note that periodontal cleanings are covered as a Major Benefit and routine cleanings are covered as a Diagnostic and Preventive Benefit. See note on additional benefits during pregnancy.

Full-mouth x-rays and panoramic x-rays are limited to once every three (3) years while the person is an Enrollee under any Delta Dental program.

Bitewing x-rays are provided twice in a Calendar Year for each Enrollee.

Topical application of fluoride solutions is limited to Enrollees under age 19.

LIMITATIONS ON BASIC BENEFITS:

Sealants are limited as follows:

To permanent first molars through age eight (8) and to permanent second molars through age 15 if they are without cavities or restorations on the occlusal surface.

Sealants do not include repair or replacement of a sealant on any tooth within two (2) years of its application.

Delta Dental will not pay to replace an amalgam, synthetic porcelain or plastic fillings or prefabricated stainless steel restorations within 24 months of treatment if the service is provided by the same Dentist.

Delta Dental limits payment for stainless steel crowns under this section to services on baby teeth. However, after consultant's review, Delta Dental may allow stainless steel crowns on permanent teeth as a Major Benefit.

Space maintainers are limited to the initial appliance only and to Enrollees under age 14.

LIMITATIONS ON MAJOR BENEFITS:

Benefits for periodontal scaling and root planing in the same quadrant are limited to once in every 24-month period. See note on additional benefits during pregnancy.

Delta Dental will not pay to replace any crowns, inlays/onlays, or cast restorations which the Enrollee received in the previous five (5) years under any Delta Dental program or any program of the Contract holder.

Prosthodontic appliances that were provided under any Delta Dental program will be replaced only after five (5) years have passed, except when Delta Dental determines that there is such extensive loss of remaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made satisfactory. Replacement of a prosthodontic appliance not provided under a Delta Dental program will be made if Delta Dental determines it is unsatisfactory and cannot be made satisfactory.

The initial installation of a prosthodontic appliance is not a Benefit unless the prosthodontic appliance, bridge or denture is made necessary by natural, permanent teeth extraction occurring during a time the Enrollee was eligible under a Delta Dental program.

Delta Dental limits payment for dentures to a standard partial or denture (coinsurances apply). A standard denture means a removable appliance to replace missing natural, permanent teeth that is made from acceptable materials by conventional means.

Delta Dental will not pay for implants (artificial teeth implanted into or on bone or gums), their removal or other associated procedures, but Delta Dental will credit the cost of a crown or standard complete or partial denture toward the cost of the implant associated appliance, i.e. the implant supported crown or denture.

LIMITATIONS ON ORTHODONTIC BENEFITS:

Payment for orthodontics is provided monthly.

Orthodontic Benefits begin with the first payment due after the person becomes covered, if treatment has begun.

Benefits end with the next payment due after loss of coverage. Benefits end immediately if treatment stops or if the Contract is terminated, whichever occurs first.

Benefits are not paid to repair or replace any Orthodontic appliance furnished, in whole or in part, under this program.

Orthodontic Benefits are limited to Dependent Child Enrollees under age 26.

X-rays or extractions are not subject to the Orthodontic maximum.

Surgical procedures are not subject to the Orthodontic maximum.

Limitations on All Benefits - Optional Services that are more expensive than the form of treatment customarily provided under accepted dental practice standards are called "Optional Services". Optional Services also include the use of specialized techniques instead of standard procedures. For example:

a crown where a filling would restore the tooth;

a precision denture/partial where a standard denture/partial could be used;

an inlay/onlay instead of an amalgam restoration; or.

a composite restoration instead of an amalgam restoration on posterior teeth.

If you receive Optional Services, Benefits will be based on the lower cost of the customary service or standard practice instead of the higher cost of the Optional Service. You will be responsible for the difference between the higher cost of the Optional Service and the lower cost of the customary service or standard procedure.

EXCLUSIONSDELTA DENTAL DOES NOT PAY BENEFITS FOR:

treatment of injuries or illness covered under workers 'compensation or employers' liability laws; services received without cost from any federal, state or local agency, unless this exclusion is prohibited by law.

cosmetic surgery or dentistry for purely cosmetic reasons.

services for congenital (hereditary) or developmental (following birth) malformations, including but not limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except those services provided to newborn children for cleft lip or cleft palate.

treatment to restore tooth structure lost from wear, erosion or abrasion; treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion; or treatment to stabilize the teeth. Examples include but are not limited to: equilibration, periodontal splinting or occlusal adjustment.

any Single Procedure started prior to the date the Enrollee became covered for such services under this program.

charges by any hospital or other surgical or treatment facility and any additional fees charged by the Dentist for treatment in any such facility.

charges for anesthesia, other than general anesthesia and IV sedation administered by a licensed Dentist in connection with covered oral surgery or selected endodontic and periodontal surgical procedures.

extraoral grafts (grafting of tissues from outside the mouth to oral tissues).

treatment performed by someone other than a Dentist or a person who by law may work under a Dentist's direct supervision.

services or supplies covered by any other health plan of the Contract holder.

treatment rendered by a person who ordinarily resides in your household or who is related to you (or to your spouse) by blood, marriage or legal adoption.

the initial placement of any prosthodontic appliance, unless such placement is needed to replace one or more natural, permanent teeth extracted while the Enrollee is covered under this Contract or was covered under any dental care program with Delta Dental. The extraction of a third molar (wisdom tooth) will not qualify under the above. Any such Prosthodontic appliance or implant must include the replacement of the extracted tooth or teeth.

services for Orthodontic treatment (treatment of malocclusion of teeth and/or jaws) for first year benefits.

services for any disturbances of the temporomandibular (jaw) joints.

L. Disclaimer
This is a general group summary of the features of the Delta Dental Insurance Company plan issued to Benefits Association, Inc. When you purchase the plan you will receive a Certificate of Coverage that details your rights and obligations, as well as those of the insurance company.

This website provides a very brief description of some of the important features of this plan. It is not the insurance contract, nor does it represent the insurance contract. A full description of benefits, exceptions and limitations is contained in the Certificate of Coverage